Healthcare Provider Details

I. General information

NPI: 1811964281
Provider Name (Legal Business Name): JACQUELINE JOY GAGEN CNM, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

IV. Provider business mailing address

11 ALVENA AVE, SUITE 101 OB/GYN ASSOC. OF CORTLAND, MD, PC
CORTLAND NY
13045
US

V. Phone/Fax

Practice location:
  • Phone: 570-888-5858
  • Fax:
Mailing address:
  • Phone: 315-446-3904
  • Fax: 315-445-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343016
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number360384
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberF000501
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number6153461
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number6153461
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number6153461
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: